| 1195例病案首页填写项目缺陷的分析 |
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| 引用本文： | 邓琼,袁瑞良,付萍,杜立雄.1195例病案首页填写项目缺陷的分析[J].中国病案,2010,11(3):17-19. |
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| 作者姓名： | 邓琼 袁瑞良 付萍 杜立雄 |
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| 作者单位： | 湖北省十堰市太和医院信息统计室,十堰市,442000 |
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| 摘 要： | 目的对某院2008年55,569例病案首页填写项目质量的分析,以进一步提高病案首页的填写质量。方法对1195例缺陷病案首页按差错类型进行分类、统计。结果发现入院后三日内确诊日期、入出院诊断符合情况、转归栏等填写项目的缺陷问题比较严重。结论针对病案首页填写存在的主要问题,该院采取了一系列相应措施,病案首页书写质量明显提高。
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| 关 键 词： | 病案首页 填写 分析 |
Analysis of the Defects in the Front sheet of 1195 Medical Records |
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| Deng Qiong,Yuan Ruiliang,Fu Ping,Du Lixiong.Analysis of the Defects in the Front sheet of 1195 Medical Records[J].Chinese Medical Record,2010,11(3):17-19. |
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| Authors: | Deng Qiong Yuan Ruiliang Fu Ping Du Lixiong |
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| Affiliation: | Deng Qiong,Yuan Ruiliang,Fu Ping,Du Lixiong.Department of Information Statistical.Taihe Hospital of Shiyan City,Hubei Province 442000 |
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| Abstract: | Objective To improve the quality of medical records by analyzing the quality of the front sheet of 55,569 medical records in 2008.Methods 1195 medical records with defects were classified by error type and analyzed statistically.Results More serious defects were found in items as the diagnosed date within three days after admission,consistency of diagnosis between admission and discharge,and outcome.ConclusionFor the main problems in the first page,a series of corresponding measures were adopted,contributin... |
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| Keywords: | the front sheet of medical records filling analyze |
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